Policy Regarding Nursing Ratios

Literature Assessment: Nurse-Patient Ratios

Introduction

The issue of mandatory staffing ratios for hospitals to ensure that adequate quality care is available to patients. Fox and Abrahamson (2009) note that “nursing care arguably falls into the realm of protecting the common good, and therefore requires government oversight” (p. 235). The sources in this bibliography relate to this issue and provide context for it. Taken together, the sources show that there is much debate surrounding the ideal nurse-patient ratio. While some argue that the ratio should be based solely on patient need, others contend that a variety of factors must be considered. The literature does appear to show, however, that the proper ratio depends on the individual hospital and can only be determined through careful analysis. For example, units with a high admissions rate will require more staff than those with a lower admissions rate. Similarly, units with complex patients will require more experienced nurses than those with simpler cases. Regardless, if a hospital is short on staff or supplies, it will not be able to provide the same level of care as one with more resources. What follows is a literature assessment regarding common themes, assumptions, approaches, weaknesses, limitations, and implications for future research.

Common Themes, Assumptions, and Approaches

A review of the literature on nurse-patient ratios reveals several common themes, assumptions, and approaches. First, there is a general consensus that proper staffing is essential for providing quality patient care (ANA, 2019; Dousay et al., 2016; Fowler & Comeaux, 2017; Martin, 2015; Twigg et al., 2015). The common assumption is that proper ratios would improve quality of course. However, this assumption is not shared by all; Reiter et al. (2012) for instance argue that mandatory staffing ratios will increase labor costs, which will increase care costs, and which could potentially lead to worse quality care. Clarke and Aiken (2003), moreover, argue that quality staffing is what policy should address, not ratios.

Second, there is a significant amount of research indicating that nurse-patient ratios have a direct impact on patient outcomes. The same authors generally agree on this point (ANA, 2019; Dousay et al., 2016; Fowler & Comeaux, 2017; Martin, 2015; Twigg et al., 2015). But there is also some research which suggests that the ratio does not have a direct impact on patient outcomes (Clarke & Aiken, 2003). It is the approach of the latter source that distinguishes it from the others: Clarke and Aiken (2003) look at entirely different variables and apply an entirely different theoretical lens when analyzing their data.

Third, there is a significant body of evidence suggesting that lower nurse-patient ratios are associated with better patient outcomes, and once more it is the same researchers who show this (ANA, 2019; Dousay et al., 2016; Fowler & Comeaux, 2017; Martin, 2015; Twigg et al., 2015). The assumption is that more nurses per patient means better care. Not all authors agree, but supporting literature by Laschinger and Fida (2015) and Rondeau and Wagar (2016) shows that nursing shortages due to turnover stem from nursing dissatisfaction, which stems from high nurse-patient ratios.

Finally, there is some recognition that proper staffing levels are not always achievable in practice due to resource constraints (Fox & Abrahamason, 2009; Reiter et al., 2012). However, the majority of authors indicate that policy should nonetheless be changed to mandate staffing ratios. These themes, assumptions, and approaches provide a useful framework for understanding the current state of research on the topic of nurse-patient ratios.

Common Sources Cited across the Literature

There was no evidence of common sources being cited across the literature, as each article chose a different focus or approach to the topic. Some were qualitative and some looked at quantitative data. Some looked at nurse satisfaction levels, and some looked at quality care issues. Most of the data sources of information include surveys of nurses and patients, as well as anecdotal reports. However, these sources may be less reliable than data obtained through the National Database of Nursing Quality Indicators, which collects data from more than 3,600 hospitals across the United States.

Common Weaknesses or Limitations

Although there is a great deal of literature on the importance of maintaining a proper nurse-patient ratio, there are several common weaknesses or limitations that should be noted. First, many studies fail to take into account the specific needs of the patients. For instance, a study might focus on the average number of patients per nurse, without considering the fact that some patients may require more care than others (Clarke & Aiken, 2003).

Second, many studies fail to control for other important variables, such as the experience of the nurses or the type of facility in which they work (Laschinger & Fida, 2015; Reiter et al., 2012). Control variables are often lacking in these studies, which is shown to be a problem when another group of researchers like Reiter et al. (2012) expose it as one. The studies generally do not test hypotheses using a gold star standard but rather examine literature and look at small samples for testing certain variables but never looking at control groups.

Third, some studies suffer from small sample sizes, which can lead to biased results (Reiter et al., 2012). Despite these limitations, however, the literature on nurse-patient ratios provides valuable insight into this important issue by arguing that when the nurse-patient ratio is too high, nurses are more likely to experience burnout and job dissatisfaction (Dousay et al., 2016; Fowler & Comeaux, 2017; Martin, 2015). In turn, this can lead to a decline in the quality of patient care (ANA, 2019; Clarke & Aiken, 2003). Moreover, high nurse-patient ratios have been linked to an increased incidence of medical errors and adverse events (Twigg et al., 2015). On the other hand, when the nurse-patient ratio is lower, nurses report feeling more satisfied with their jobs and provide better-quality care (Dousay et al., 2016; Rondeau & Wagar, 2016). In addition, patients in these settings have better health outcomes (Martin, 2015). Therefore, the literature on nurse-patient ratios provides valuable insight into this important issue by demonstrating the effects that different ratios can have on both nurses and patients, in spite of limitations due to sample size, method, design, or approach.

Common Errors or Oversights

Common errors or oversights in this department would include lack of discussion of control variables, lack of a control group to test hypotheses, lack of variation in approaches taken, too much willingness to accept a basic assumption instead of testing it with respect to nurse-patient ratios being all that is needed to improve quality of care, and lack of a robust sample size or methodology.

One issue that is not unique to just a few studies is the issue of validity, in which little discussion or attention is given to triangulation or the use of multiple sources for data. While in some literature reviews, multiple studies may be cited, there is a lack of attention given to ensuring validity all too often. Save for the studies by Reiter et al. (2012) and Clarke and Aiken (2003) the other studies seem to have a narrow focus that does not permit alternative explanations for what is going on.

Implications for Future Research

There are still some areas where more research is needed in order to develop evidence-based policy recommendations. For example, more research is needed on the impact of nurse-patient ratios on specific patient populations, such as those with chronic illness or multiple comorbidities. In addition, more research is needed on the economic impact of nurse-patient ratios, as this is an important consideration for policy makers (Reiter et al., 2012). Ultimately, the implications of this research are that policies on nurse-patient ratios should be based on the best available evidence in order to ensure the best possible outcomes for patients.

So far the research has generally concentrated on what nurse-patient ratios should be according to a basic approach represented by numerous studies (ANA, 2019; Dousay et al., 2016; Fowler & Comeaux, 2017; Martin, 2015; Twigg et al., 2015). Yet what could be called as outlier literature or transgressive literature like the study by Reiter et al. (2012) shows that the policy cannot be approached so simplistically because there are costs that must be taken into consideration. Likewise, the study by Clarke and Aiken (2003) shows that ratios will be meaningless if quality of nursing itself is not addressed within the policy as well.

Nurse-patient ratios remain a hot-button issue in the nursing community, with passionate advocates on both sides of the debate (ANA, 2019; Reiter et al., 2012). However, there is still much that researchers do not know about the effects of mandatory nurse-patient ratios (Clarke & Aiken, 2003). In order to improve patient care, future research should focus on three key areas: the effect of ratios on specific patient populations, the impact of ratios on nurses’ job satisfaction, and the cost-effectiveness of mandatory nurse-patient ratios.

Studies on the effects of nurse-patient ratios have been inconclusive so far, with some finding positive effects and others finding no significant difference—especially when certain variables are included for examination (Clarke & Aiken, 2003). However, most of these studies have been relatively small in scale. Future research should be large-scale and longitudinal in order to provide more definitive answers. Additionally, research has largely focused on general medical/surgical units. There is a need for more studies that look at the effect of mandatory nurse-patient ratios on specific populations such as NICU patients or psychiatric patients.

Another area that warrants further study is the impact of mandatory nurse-patient ratios on nurses' job satisfaction. It is possible that the effect of nurse-patient ratios on job satisfaction varies depending on the type of unit or the type of patient population. This is an area that warrants further exploration.

Finally, although there is some evidence that mandatory nurse-patient ratios can improve patient outcomes, there is still much debate about whether or not they are cost-effective (Reiter et al., 2012). A comprehensive cost-benefit analysis is needed in order to determine whether or not mandating nurse-patient ratios is worth the expense.

Common Conclusions

A common conclusion in this literature is that lower ratios are associated with better patient outcomes. In particular, lower ratios have been linked to reduced mortality rates, shorter lengths of stay, and fewer medications errors (ANA, 2019; Dousay et al., 2016; Fowler & Comeaux, 2017; Martin, 2015; Twigg et al., 2015). These findings suggest that policies that mandate higher nurse-patient ratios could have a positive impact on patient care.

However, it is important to note that the evidence is far from conclusive (Clarke & Aiken, 2003). Some studies have found no link between nurse-patient ratios and patient outcomes, while others have found that the direction of the relationship depends on contextual factors such as hospital type or patient population (Clarke & Aiken, 2003; Reiter et al., 2012). As such, more research is needed to fully understand the implications of policy changes on nurse-patient ratios.